Secondary sclerosing cholangitis in localized hepatobiliary tuberculosis simulating cholangiocarcinoma: a rare case report

BACKGROUND

Hepatobiliary tuberculosis includes miliary, tuberculous hepatitis or localized forms. The localised form is extremely uncommon and can mimic malignancy. Still rarer is its presentation as sclerosing cholangitis.

CASE PRESENTATION

A 50 year male presented with acute onset jaundice, significant weight loss and elevated liver enzymes with clinico-radiological suspicion of cholangiocarcinoma. A left hepatectomy was done and dilated bile ducts filled with caseous necrotic material were seen intra-operatively. Histopathology suggested localized hepatobiliary tuberculosis with features of secondary sclerosing cholangitis.

CONCLUSION

Localised hepatobiliary tuberculosis can cause diagnostic difficulties and its possibility should be considered especially in endemic areas.

Tubercular biliary hilar stricture: A rare case report

Localized hepatic tuberculosis (TB) with or without bile duct involvement is a rare form of hepatobiliary tuberculosis; accounting for less than 1% of all tuberculous infections. We report an uncommon case of cholestatic jaundice with disseminated TB in an immunocompetent male who presented with simultaneous involvement of liver and biliary system.

Altered Liver Proteoglycan/Glycosaminoglycan Structure as a Manifestation of Extracellular Matrix Remodeling upon BCG-induced Granulomatosis in Mice

Experimental BCG-induced granulomatosis in mice was used to study changes in the dynamics of individual liver proteoglycan components reflecting phasic extracellular matrix remodeling, determined by the host-parasite interaction and associated with granuloma development. In the early BCG-granulomatosis period, the increase in individual proteoglycan components promotes granuloma formation, providing conditions for mycobacteria adhesion to host cells, migration of phagocytic cells from circulation, and cell-cell interaction leading to granuloma development and fibrosis. Later, reduced reserve capacity of the extracellular matrix, development of interstitial fibrosis and granuloma fibrosis can lead to trophic shortage for cells within the granulomas, migration of macrophages out of them, and development of spontaneous necrosis and apoptosis typical of tuberculosis.

Localized Hepatic Tuberculosis with Imaging Changes Caused by the Progression of Tuberculosis

Localized hepatic tuberculosis (LHTB) is difficult to diagnose preoperatively, and most cases of LHTB are diagnosed based on pathological findings. A relationship between imaging features and the pathological stage of hepatic tuberculosis (TB) has recently been reported, which could aid in the diagnosis of hepatic TB. We herein present a case study of a patient with LHTB diagnosed postoperatively who demonstrated imaging changes due to the progression of TB. An awareness of the presence of LHTB might have permitted a preoperative diagnosis. This is the first report of an LHTB patient who exhibited imaging changes during the course of the disease.

A rare case of isolated macronodular hepatic tuberculosis (Tuberculous) in an immunocompetent patient

Tuberculosis is one of the most common and well described infectious diseases, with a world wide distribution and a vast spectrum of clinical manifestations. There are three forms of hepatic tuberculosis. Diffuse hepatic involvement with pulmonary or miliary tuberculosis, diffuse hepatic infiltration without recognizable pulmonary involvement is the second form and the third very rare form presents as a focal/local tuberculoma or abscess. In this case report we describe an unusual appearance of macronodular tuberculomas of the liver.

Tuberculous liver abscess in an immunocompetent adult male--a rare presentation

A 20 year old young male was admitted to our hospital with complaints of pain in upper abdomen right side, anorexia and loss of weight. Ultrasonography of the upper abdomen revealed a hypoechoic area in the left lobe of liver. Entertaining the possibility of pyogenic or amoebic lesion, the patient was started on ofloxacin and metronidazole. Failing to get any response to the therapeutic intervention, ultrasound guided aspiration was undertaken. The aspirated pus did not grow any organism in pyogenic or fungal culture but showed acid fast bacilli in Z.N. stain. The treatment was shifted to four drugs ATT and there was dramatic improvement in the clinical condition. This case is being reported to emphasize that ruling out tuberculosis may avoid unnecessary delays in the initiation of specific anti-tubercular treatment. Also a greater awareness of this rare clinical condition may prevent unwarranted surgical intervention.

Liver tuberculosis in an HIV patient: diagnosis and management

Hepatic involvement is common in miliary and extra-pulmonary tuberculosis but is usually clinically silent. Therefore, it is rarely diagnosed. We report the case of a patient that presented with prolonged fever and hepatomegaly. Liver biopsy revealed non-necrotizing granulomas that led in turn to the diagnosis of generalized tuberculosis and HIV infection. The patient reported an old untreated tuberculosis and depression of the immune system provoked the reactivation of this old tuberculosis focus. We describe the clinical course of the disease and the challenges associated with the complexity of the treatment. Diagnosis of hepatic tuberculosis requires a high degree of suspicion especially in AIDS patients who show atypical presentations. However, it is a potential curable disease and good results have been obtained with the four drug regimen.

The nodular form of hepatic tuberculosis: contrast-enhanced ultrasonographic findings with pathologic correlation

OBJECTIVE

The purposes of this study were to describe the ultrasonographic findings in hepatic tuberculosis (TB) after administration of a second-generation sulfur hexafluoride-filled microbubble contrast agent and to correlate these findings with pathologic characteristics.

METHODS

Twenty-four hepatic TB lesions in 15 patients were studied with conventional ultrasonography (CUS) and contrast-enhanced ultrasonography (CEUS). Pathologic characteristics of the lesions were evaluated and were then correlated with enhancement patterns.

RESULTS

The appearance of hepatic TB on CUS was variable and nonspecific with respect to the shape, echogenicity, and boundary of the lesions. The diameters of the lesions obtained from CEUS were statistically larger than those from CUS, with largest diameters +/- SD of 4.2 +/- 1.8 and 3.1 +/- 1.9 cm, respectively. During the arterial phase, 13 of 24 lesions (54.2%) showed a rapidly and markedly enhanced rim with a hypoenhanced or nonenhanced center; 9 of 24 lesions (37.5%) showed transient enhancement of the whole lesion with inconsistent intensities. During the portal phase, most lesions showed distinct wash-out of the contrast agent and maintained a hypoechoic appearance. Pathologic studies confirmed that the different appearances of hepatic TB on CEUS were related to the different pathologic stages of the lesions.

CONCLUSIONS

Findings of hepatic TB on CEUS may be helpful in differentiating the diagnosis from other hepatic focal lesions. Correlation with pathologic findings would enrich the understanding of CEUS findings in hepatic TB.

Chest wall abscess: an atypical presentation of isolated tuberculous liver abscess

The incidence of hepatic tuberculosis is increasing with the resurgence of tuberculosis due to the emergence of multi drug resistant strains and to an increased prevalence of human immune-deficiency virus infection. In contrast, isolated tuberculous liver abscess (TLA) is extremely uncommon with a prevalence of 0.34% in patients with hepatic tuberculosis. We describe a case of isolated TLA in a 32-year-old immune-competent man, who presented with a painless lump in the right posterior chest wall. Fine needle aspiration revealed acid fast bacilli (AFB), computed tomogram of the thorax showed a hepatic abscess in the segments 6 and 7 communicating with the posterior chest wall. The presentation of TLA may be atypical and diagnosis remains elusive unless hepatic involvement is revealed by imaging and AFB is demonstrated in the aspirated pus or necrotic material. Open drainage of the superficial component of the abscess along with antituberculosis treatment resulted in the resolution of the abscess.

[A case of asymptomatic primary liver tuberculosis proven by percutaneous liver biopsy]

The patient, an 18-year-old girl, was found to have strong positive purified protein derivative of tuberculin (PPD) test and calcified focus in her liver 2 years ago. She denied fever, cough, sputum, weight loss, night sweats, fatigue, and anorexia. After admission, physical examination, laboratory tests, CXR, abdominal CT, colonoscopy and gynecological examination were all normal except for the liver lesions. Percutaneous needle biopsy was performed under sonographic guidance and pathological examination showed caseous granuloma. She was diagnosed as primary liver tuberculosis and the lesions decreased after 2 months' therapy of isoniazid, rifampicin and ethambutol. Primary liver tuberculosis could be asymptomatic and manifested as calcified focus; percutaneous needle biopsy and pathological examination is helpful for the diagnosis. The asymptomatic liver lesions are still an indication for anti-tuberculosis therapy.

[Acquired ichthyosis revealing hepatic and lymph node tuberculosis]

INTRODUCTION

Acquired ichthyosis is an uncommon disease usually associated with different systemic diseases. Its characteristic clinical sign is symmetrical scaling of the skin. We report a case of acquired ichthyosis revealing hepatic and lymph node tuberculosis.

CASE

A 41-year-old man was admitted to our hospital with weight loss and generalized acquired ichthyosis. Ultrasonography and computer tomography showed enlargement of abdominal lymph nodes. Lymph node and liver biopsy samples were taken during exploratory laparotomy and revealed multiple lymphoepitheliomas with Langhans-type giant cells and central caseous necrosis. The skin lesions resolved progressively after 5 months of antituberculous therapy.

DISCUSSION

Ichthyosis occurring in adulthood is often a sign of internal disease, especially malignant conditions. It has also been associated with autoimmune and infectious diseases, sarcoidosis and drugs. It is only rarely reported among patients with tuberculosis but it is possible that the ichthyosis in this case was due to weight loss and deterioration of the patient's general condition.

Massive primary hepatic tuberculoma mimicking hepatocellular carcinoma in an immunocompetent host

Tuberculoma of the liver is rare in an immunocompetent individual. We report a 26-year-old man with upper abdominal pain, abnormal liver function, and raised inflammatory markers. Abdominal computed tomography (CT) scan revealed a mixed attenuation lesion measuring 6 x 5 cm occupying most of the left lobe of the liver. Subsequent histology and culture confirmed tuberculous abscess. Following antituberculous therapy, repeat CT scan revealed complete resolution of the initial findings. This case illustrates the diagnostic difficulties of hepatic tuberculosis (TB) and the importance of considering TB in patients with hepatic lesions.

Liver involvement in tuberculosis--an autopsy study

OBJECTIVE

To study the spectrum of histopathological changes in the liver in cases of tuberculosis.

MATERIALS & METHODS

This is an autopsy study consisting of 150 adult cases of tuberculosis over a period of 3 years. The diagnosis of tuberculosis was made on the basis of caseating granulomas or acid fast bacilli in the tissue. Cases showing only healed foci of tuberculosis at autopsy were excluded. Clinical details of all cases were obtained from hospital records. At autopsy, gross examination was done meticulously with special emphasis on the liver and extrahepatic biliary tree. Sections from the liver were processed routinely and histopathological findings were analyzed in detail.

RESULTS

Patients were between 21 to 60 years of age with a male: female ratio of 2.1:1. Fever was the commonest symptom (62%). On gross examination, at autopsy, pulmonary and extrapulmonary tuberculosis was seen in 79 (52.6%) and 71 (47.4%) cases respectively. Liver involvement was mainly secondary except in one case. The extrahepatic biliary tree was involved in 18 cases, in the form of external compression of the common bile duct by a group of enlarged caseating, matted lymph nodes. The spectrum of histopathological changes of the liver showed epitheloid cell granulomas in 63 (42%), fatty changes in 49 (32.6%), inflammation in 60 (40%), sinusoidal congestion in 48 (32%) and fibrosis in 24 (16%) cases. Of the 63 cases of liver granulomas, 12 (19%) were cases of extensive pulmonary tuberculosis and the remaining were extrapulmonary tuberculosis. Granulomas were caseating in 58.7%, noncaseating in 23.8% and atypical in 17.5% cases. Fatty change ranged from mild to severe. Inflammation was mainly mild to moderate. Stage I and II fibrosis was seen in 13 (8.6%) and stage III and IV in 11 (7.3%) cases. On comparing the granuloma and non-granuloma cases histological features, it was found that fatty changes and inflammation were more with granuloma formation but there was no difference in the degree of fibrosis in the two groups.

CONCLUSION

Liver involvement was mainly in the form of secondary tuberculosis. On histopathology, epitheloid cell granulomas were seen in 42% cases, other changes were non-specific. Significant fibrosis was seen in 7.3% cases however the finding of tuberculosis as a cause of significant fibrosis was not consistent.

[A clinical analysis of 57 cases of abdominal tuberculosis]

OBJECTIVE

To explore the clinical characteristics and diagnosis methods of abdominal tuberculosis.

METHODS

The clinical characteristics of abdominal tuberculosis in 57 cases proved by histopathology between 1958-2004 were retrospectively analyzed.

RESULTS

There were 39 cases of tuberculosis of the liver, 5 cases of the spleen, 8 cases of the pancreas, 3 cases of the stomach, 1 case involved both liver and spleen and 1 case involved both liver and stomach. Twenty-six patients were males and 31 female; with ages ranged from 17 to 68 years (mean 40.7 years) and most cases (71.9%) having extra-abdominal tuberculosis. Fever (75.4%), fatigue, anorexia, night sweating, weight loss (82.5%) and hepatosplenomegaly (57.9%) were the major clinical manifestations. Elevated erythrocyte sedimentation rate (ESR) (59.6%) and abdominal mass (64.9%) were found in most of the patients.

CONCLUSIONS

The diagnosis of abdominal tuberculosis should be considered in all patients with fever of unknown origin, especially in those associated with hepatosplenomegaly, increased ESR and abdominal mass. Aspiration biopsy and laparotomy can provide correct diagnosis. The disease can be effectively treated with surgical intervention and antituberculous chemotherapy.

Enlarged cervical lymph nodes and elevated liver chemistry tests: a therapeutic dilemma

We describe the case of a 36-years-old male patient, originating from India, who presented with enlarged cervical lymph nodes and elevated liver chemistry tests. Histologically necrosing granulomas were observed in the lymph nodes, and PCR revealed DNA from mycobacterium tuberculosis. However, in the liver biopsy granulomatous hepatitis without central necrosis was seen. With a positive PCR for mycobacteria from liver tissue and no evidence for other hepatic diseases we started drug treatment with standard quadruple regimen consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide. Five days after onset of therapy, liver chemistry tests rose 10-fold, forcing us to interrupt treatment. Gradual step-wise re-exposition with the same medication after return of liver chemistry tests to baseline was well tolerated without any further side effects. Liver involvement of tuberculosis can have many facets and may be treated by gradual dosing of standard drugs.

Hepatic tuberculosis mimicking carcinoma gall bladder

We report a 50-year-old man with tuberculosis of the liver with calculous cholecystitis. The diagnosis was made when the patient underwent cholecystectomy. He responded to antitubercular therapy.

The infected liver: radiologic-pathologic correlation

Recent technologic advances have significantly enhanced the role of imaging in the detection, characterization, and management of infectious diseases involving the liver. In addition, imaging-guided percutaneous drainage has greatly improved the clinical treatment of patients with focal liver abscess. Infectious liver diseases can be accurately evaluated with ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging. Characteristic changes in US echogenicity, CT attenuation, or MR imaging signal intensity and typical enhancement patterns can contribute to the diagnosis of specific infectious diseases, including abscesses, parasitic diseases, fungal diseases, granulomatous diseases, viral hepatitis, and other less common infections. CT is particularly helpful in revealing the presence of calcifications and gas and in detailing the enhancement pattern. The multiplanar capability of MR imaging and its sensitivity to small differences in tissue composition increase its specificity for certain hepatic infections, including hydatid cyst and candidiasis. Radiologic findings may be sufficient to obviate aspiration or histologic examination, although in most instances they are less specific. Nevertheless, imaging findings taken together with appropriate clinical information may provide the most likely diagnosis, even if biopsy is sometimes required for confirmation.

Hepatic pathology in AIDS: a pathological study from Mumbai, India

OBJECTIVES

To assess the spectrum of hepatic disorders in AIDS, liver specimens from 171 patients (155 autopsies and 16 biopsies) were reviewed.

METHODS

A retrospective and prospective study of 171 autopsy and biopsy specimens was carried out at a tertiary level hospital in Mumbai, India.

RESULTS

Of the patients included in the study, 127 (74%) were male and 44 (26%) were female. The heterosexual route was the predominant mode of HIV transmission, identified in 163 (95%) patients. A total of 99 of 171 patients (58%) showed significant pathological lesions, and the most common pathological processes involving the liver appeared to be secondary to infections. None of our patients showed isolated infectious diseases of the liver. The spectrum of liver diseases identified was as follows: tuberculosis in 70 patients (41%), cryptococcosis in eight (5%), cytomegalovirus infection in six (3%), hepatitis B infection in five (3%), candidiasis in one (0.5%), malaria in one (0.5%), cirrhosis in six (3%), amyloidosis in one (0.5%) and primary hepatic lymphoma in one (0.5%).

CONCLUSIONS

AIDS patients were found to have a high prevalence of underlying hepatic abnormalities. The spectrum of disease among patients with AIDS in India differs from that in developed countries. Our results suggest that hepatic tuberculosis is more common in AIDS than previously recognized, and that liver specimens should be examined routinely for the presence of acid-fast bacilli.

Isolated hepatic tuberculous pseudometastasis co-existent with adenocarcinoma of the stomach; report of a case

A 10 x 9 mm metastasis-like lesion in segment V of the liver was detected, when a 70-year-old man was operated on for adenocarcinoma of the stomach. Since exact diagnosis of the hepatic lesion could not be made by frozen sections, the lesion was excised, considering it to be a metastasis of gastric adenocarcinoma. Bacteriologic and pathologic studies established a diagnosis of isolated tuberculosis of the liver. A good response to antituberculous drug therapy was noted.

Imaging diagnosis of 12 patients with hepatic tuberculosis

AIM

To assess CT, MR manifestations and their diagnostic value in hepatic tuberculosis.

METHODS

CT findings in 12 cases and MR findings in 4 cases of hepatic tuberculosis proved by surgery or biopsy were retrospectively analyzed.

RESULTS

(1) CT findings: One case of serohepatic type of hepatic tuberculosis had multiple-nodular lesions in the subcapsule of liver. Parenchymal type was found in 10 cases, including multiple, miliary, micronodular and low-density lesions with miliary calcifications in 2 cases; singular, low-density mass with multiple flecked calcifications in 3 cases; multiple cystic lesions in 1 case; multiple micronodular and low-density lesions fusing into multiloculated cystic mass or "cluster" sign in 3 cases; and singular, macronodular and low-density lesion with multiple miliary calcifications in 1 case. One case of tuberculous cholangitis showed marked dilated intrahepatic ducts with multiple flecked calcifications in the porta hepatis. (2) MR findings in 4 cases were hypointense on both T1-weighted imagings and T2-weighted imagings in one case, hypointense on T1-weighted imagings and hyperintense on T2-weighted imagings in 3 cases. Enhanced MR in 3 cases was slightly shown peripheral enhancement or with multilocular enhancement.

CONCLUSION

Various types of hepatic tuberculosis have different imaging findings, and typical CT and MR findings can suggest the diagnosis.

The nodular form of hepatic tuberculosis: a review with five additional new cases

BACKGROUND

Tuberculosis presenting as an isolated liver tumour, without active pulmonary or miliary tuberculosis, or other clinical evidence of tuberculosis, is distinctly rare. A greater awareness of this rare clinical entity may prevent needless surgical intervention.

AIMS

To help characterise this distinctly rare presentation of tuberculosis, five new cases are presented, together with a review of the world literature. The clinical, laboratory, radiological, and pathological features of these patients are described.

METHODS

Polymerase chain reaction (PCR) assay of the liver tissue was carried out in all cases to confirm an aetiological diagnosis of Mycobacterium tuberculosis infection.

RESULTS

All five patients (44-71 years old; two women, three men) underwent surgery, and had a preoperative diagnosis of malignant hepatic neoplasm and a postoperative histological diagnosis of chronic granulomatous inflammation, suggestive of tuberculosis. None of them had a known previous history of tuberculosis. All of them were positive for M tuberculosis by PCR analysis of the liver tissue.

CONCLUSIONS

This report illustrates the difficulty in reaching a correct preoperative diagnosis. It is usually unsuspected and confused with primary or metastatic carcinoma of the liver, especially when it coexists with other malignancies. A high index of suspicion is required for diagnosis, which can be made only by histological and bacteriological studies, and PCR analysis.

Isolated tuberculous liver abscesses with multiple hyperechoic masses on ultrasound: a case report and review of the literature

Cases of isolated tuberculous liver abscess are rare. The diagnosis is often delayed or missed because of nonspecific symptoms and the disease's rare occurrence. Less than 25 cases have been documented in the imaging literature to date. This report demonstrates the difficulty in correctly diagnosing local hepatic tuberculosis. We report the case of a 56-year-old male with hepatitis C-related liver cirrhosis and end-stage renal disease treated with hemodialysis, who developed intermittent fever and hepatomegaly with unusual multiple hyperechoic hepatic lesions on ultrasound. To our knowledge, this is only the second reported case of hyperechoic mass-like hepatic lesions on ultrasound and the only case without pulmonary involvement. A greater awareness of this rare clinical entity may prevent needless surgical interventions, because the prognosis of hepatic tuberculous abscess is good for the majority of patients if diagnosed early and prompt, effective treatment is administered.

[Bacterial granulomatous hepatitis]

The liver may react to different infectious and non- infectious agents, developing granulomatous lesions which characterize granulomatous hepatitis. Granulomas of the liver are circumscribed inflammatory lesions (size from 50 to 300 mm) composed of epithelioid cells, varied numbers of mononuclear cells and eosinophils and multinucleated giant cells. They represent a specialized cell-mediated immune response to a wide variety of etiological factors. A broad spectrum of microorganisms may trigger hepatic granulomas. M. tuberculosis is the more frequent agent (~ 44%). Granulomatous hepatitis is characterized by a febrile illness with systemic signs and symptoms such as fatigue, sweating, shivering, hepatomegaly and/or splenomegaly, abnormalities in serum liver tests (aminotransferase, alkaline phosphatase). Liver biopsy provides diagnostic information in approximately 15-30% of cases, identifying directly the microbial agent with special microbial stains and polymerase chain reaction or finding distinctive microscopic features, suggestive of specific microorganisms. In such cases appropriate therapy is possible. Unfortunately in one third of cases is impossible to reach aetiological diagnosis on histological criteria alone. In these cases a therapeutic attempt with steroids, effective in the idiopathic granulomatous hepatitis, may be useful.

Hepatic sarcoidosis

We describe six cases of hepatic sarcoidosis. Clinical presentation was with weight loss, hepatomegaly and abnormal liver function tests. In addition there was fever, itching, splenomegaly and abdominal lymphadenopathy in some. CT scan revealed mediastinal lymphadenopathy in all. Liver biopsy showed noncaseating epithelioid granulomas. Serum angiotensin converting enzyme was elevated in four cases. All patients had received anti-tuberculosis treatment with clinical diagnosis of hepatic tuberculosis. None of them improved, while some showed clinical deterioration. All patients responded to corticosteroids with disappearance of symptoms and normalization of liver function tests.

[Granulomatous tuberculous hepatitis as cause of fever of unknown origin]

The clinical case of one patient with fever of unknown origin, due to granulomatous hepatitis of tuberculous etiology was presented. The patient was a a 50-year-old woman, with 50 days illness characterized by chills, 39 degrees C fever and heavy diaphoresis. She had a record of seven malaria cases. She looked thin and pale at the initial physical examination. During the evolution, she developed pancytopenia, massive hepatosplenomegaly, jaundice, and anasarca. The patient underwent screening tests for infection, neoplasias, collagenosis, and granulomatous diseases. The laboratory tests showed transaminase-alkaline phosphatase dissociation, which led to the final diagnosis of tuberculosis, through the histological examination of the liver parenchyma. The specific treatment against tuberculosis caused remission of fever, ascites, and hepatomegaly and normalization of liver tests, with satisfactory clinical evolution.

Correlation of ultrasonographic findings with ultrasound guided fine needle aspiration of liver lesion

Ultrasonographic findings of liver were correlated with cytological findings in a series of 50 patients. Multiple lesions described by ultrasonography and suggested as HCC/TB were proved to be metastatic in 60% cases and hepatocellular carcinoma in 40% cases by cytological examination. Multiple lesions suggested as metastatic lesions in ultrasonography was proved as such by cytology in 83% cases. Solitary lesion suggested as neoplastic in ultrasonography was proved as such in cytology in 90% cases. Of the 2 patients suggested as diffuse parenchymal lesion revealed cytological findings of cirrhosis in one case and that of TB in other. Serum alpha-feto protein and Carcinoembryogenic antigen (CEA) was done in all the cases. Serum alpha-feto protein was higher in hepatocellular carcinoma and CEA was higher in metastatic lesions. Ultrasound guided fine needle aspiration of liver can play more role in diagnosis and classification of liver disease than ultrasonographic comment alone, as it requires greater degree of precision to reach diagnostic accuracy.

Computed tomography and angiography in hepatic tuberculosis mimicking liver tumor

Tuberculosis is one of the most common and well-documented infectious diseases, with a vast variety of clinical manifestations. A case of isolated hepatic tuberculosis mimicking liver tumor is presented. The patient was a 44-year-old man who had suffered from intermittent epigastralgia for about 2 years. Abdominal computed tomography demonstrated a low density mass with internal calcification over the left lobe of the liver. Celiac angiography showed encasement of the hepatic propia and occlusion of the left hepatic artery. Abnormal tortuous vascular structures were found at the hepatic hilar region. The patient underwent surgical intervention under the impression of left liver tumor. Microscopically, the resected liver tissue specimen revealed tuberculosis.

[Effects of mixture of fermented whey SGOL-1-40 ("Sgidolac") and sterilized milk on the course of experimental tuberculosis]

The effect of enzymolic whey SGOL 1-40 ("Sgidolac") and sterilized milk mixture on experimental tuberculosis process with mice has been investigated. The mice of CBA line infected with tuberculosis (Type H37Rv) and been given this mixture (rate SGOL 1-40 to milk 1:5) per os immediately after the infection at the amount of 0.5 g/Kg body weight per day every day, perished on 42-nd day, meanwhile the mice that had received the mixture 3 weeks before the infection and all the period after it, died on 46-th day he mice in the control group (infected and untreated) died on the 38-th day. The positive treatment and prophylactic effect of the SGOL 1-40 and milk mixture on the tuberculosis process has been stated and morphologically proved.

Generalized tuberculosis in the acquired immune deficiency syndrome

OBJECTIVE

Generalized, or hematogenously disseminated, tuberculosis (TB) in patients with the acquired immune deficiency syndrome (AIDS) has been associated with a high incidence of cases remaining undiagnosed until postmortem. To better characterize generalized TB in the setting of AIDS, this report describes the clinical, laboratory, radiologic, and pathologic features of 20 fatal cases.

DESIGN

The medical records, autopsy protocols, and histologic material from patients with AIDS and concomitant TB were reviewed. All patients were autopsied at a tertiary care medical center during the years 1985-1997.

RESULTS

In 50% of our 20 cases, diagnosis was not made until postmortem. Signs and symptoms were few, including the absence of fever (temperature > or = 38 degrees C) in 55% of patients. Consistent laboratory abnormalities of a nonspecific nature were limited to hyponatremia (sodium <135 mmol/L) in 60%. Both peripheral and deep (thoracic and abdominal) lymphadenopathy, unusual in adults with TB, occurred in 45% and 95% of cases, respectively. In contrast to previous reports, all of the 6 cases of tuberculous meningitis presented as acute meningitis with a predominance of neutrophils in cerebrospinal fluid. Necrotizing encephalitis with extension of the acute inflammation into the superficial cortex was seen in all cases and tuberculous brain abscesses occurred in 50% of cases, a higher frequency than previously reported. Despite lung involvement in 90% of the cases, 33% of chest radiographs were interpreted as normal and disseminated mycobacterial disease was not suggested in the radiograph report in any of the other cases. Soft tissue abscesses in uncharacteristic locations such as the neck, mediastinum, and perirectal area occurred in these patients. Histologically, 95% of organs sampled showed inflammatory foci characterized by extensive necrosis with numerous neutrophils and/or karyorrhectic debris, numerous acid-fast bacilli, few or no epithelioid histiocytes, and no Langhans giant cells.

CONCLUSION

Clinically and pathologically, generalized TB in the setting of AIDS is characterized by either unusual features or a lack of the typical features described for generalized TB in patients who do not have AIDS. This absence of classic features contributes to the high incidence of cases that remain undiagnosed until postmortem examination.

NOS2-derived nitric oxide regulates the size, quantity and quality of granuloma formation in Mycobacterium avium-infected mice without affecting bacterial loads

Granuloma formation in response to mycobacterial infections is associated with increased expression of inducible nitric oxide synthase (NOS2) within granuloma macrophages and increased levels of nitrate/nitrite in the sera of infected mice. Continuous treatment with 5 mm or 10 mm l-N6-(1-imino-ethyl)-lysine (L-NIL), a selective NOS2-inhibitor, in acidified drinking water for up to 7 weeks consistently reduced infection-induced nitrate/nitrite to background levels in mycobacteria-infected BALB/c mice. Oral treatment with 5 mm L-NIL initiated at the time of infection significantly exacerbated growth of Mycobacterium tuberculosis, but had no effect on Mycobacterium avium colony-forming unit development in the liver, spleen and lungs of intravenously infected mice. In order to examine the role of nitric oxide in mycobacteria-induced granulomatous inflammation in the absence of any effect on the bacterial load, M. avium-infected mice were treated with 5 mm L-NIL from day 1 through 38 and the development of granulomatous lesions in the liver was assessed by histology, immunohistology and reverse-transcription-polymerase chain reaction (RT-PCR). Computer- and video-assisted morphometry performed at 4 and 7 weeks post-infection showed that treatment with L-NIL led to markedly increased number, cellularity and size of granulomatous lesions in infected mice regardless of the virulence of the M. avium isolate used for infection. Immunohistology of the liver revealed that in mice treated with L-NIL, the numbers of CD3+ T cells, CD21/35+ B cells, CD11b+ macrophages and RB6-8C5+ granulocytes associated with granulomatous lesions was increased. RT-PCR of the liver showed that in L-NIL-treated mice infected with M. avium, mRNA levels of tumour necrosis factor, interleukin-12p40, interferon-gamma, interleukin-10 and interferon-gamma-inducible protein-10 (IP-10) were up-regulated, while mRNA levels of interleukin-4, monocyte chemotactic protein-1 (MCP-1) and MCP-5 were similar to those in untreated control infected mice. When M. avium-infected mice were treated with 5 mm L-NIL between the 5th and 12th weeks of infection, similar changes in granuloma number and size were found in the absence of any effect on the bacterial load. These findings demonstrate that nitric oxide regulates the number, size and cellular composition of M. avium-induced granulomas independently of antibacterial effects by modulating the cytokine profile within infected tissues.

[Evolution of granulomas induced by BCG vaccine administered in the experiment]

The time course of hepatic granulomatosis was studied on a CBAxC57B1/6 murine model of a vaccinal process induced by BCG vaccine. It was found that over the natural course of inflammation, there were changes in the spectrum of granulomas from epithelioid cellular to macrophageal and fibrotic ones with stabilization of their sizes, averaged cellular composition and density in the organ. Long-term use of isoniazid caused a considerably (2-fold) reduction in the number of granulomas in the organ and thus a decrease in the level of its fibrotic process. Presumably, in the treated animals, the mechanism responsible for a reduction in the number of granulomas is the "dissociation" of macrophageal cells from them.

Sites of tuberculous involvement in patients with AIDS. Autopsy findings and evaluation of gallium imaging

The purpose of this study was to review autopsy and gallium scan findings in two different acquired immune deficiency syndrome (AIDS) patient populations who had a confirmed diagnosis of tuberculosis (TB) to identify organs involved and accuracy of clinical diagnosis. The first group was comprised of 29 autopsies between January 1982 and December 1994, including only 18 patients who were diagnosed before death. Organs most commonly involved were the lymph nodes (59%), lungs (56%), spleen (53%), liver (45%), and kidneys (37%). Other opportunistic infections were present in 18 (59%) of autopsies, with more than one opportunistic infection present in 11 (37%) of the autopsies. Lungs were involved in 79% of all autopsies. The second population group included 94 patients with AIDS with a proven diagnosis of TB, only 24 of whom had gallium scans in the period between January 1992 and December 1994. Chest x-ray results were negative in 4 patients (17%); gallium scan results were positive in 16 patients (66%). The reasons for false-negative gallium scan results were due to anti-tuberculous treatment for periods varying from 2-21 months in 7 patients or the presence of extra pulmonary tuberculosis. The sites of TB involvement in the chest were: lung parenchyma in 5 patients (19%, 4 in mid and lower lung, and 1 in upper fields). There was lymph node involvement in all 16 patients (24 locations with mediastinal involvement in 23%, supraclavicular 23%, axillary 11%, retroperitoneal 11%, and inguinal region in 4%. We conclude that (1) tuberculosis in patients with AIDS behaves similar to primary tuberculosis; (2) the combination of chest x-ray and gallium imaging is sensitive for the diagnosis of pulmonary tuberculosis in patients with AIDS; (3) the involvement of mediastinal lymph nodes in gallium scans in the presence or absence of chest x-ray abnormalities should raise the possibility of TB involvement in patients with human immunodeficiency virus; (4) anti-TB treatment decreases the sensitivity of gallium scan.

[Isolated tuberculosis of the liver coincident with renal cell carcinoma]

The macronodular form of hepatic tuberculosis is a very rare disease characterized by tumor-like tuberculomas or abscesses. Correct diagnosis is hampered by ambiguous clinical and radiological findings. We present a case of solitary tuberculosis of the liver without evidence of extrahepatic tuberculous manifestations. The lesions mimicked metastatic disease of a coincidentally found kidney tumor. Diagnosis could only be made by histologic examination of repeated percutaneous liver biopsies. Antituberculous treatment lead to a complete retrogression of hepatic changes while the kidney tumor (histologically a renal cell carcinoma) was removed surgically. As a liver biopsy provides the only means of diagnosing local nodular tuberculosis, which is treatable, we conclude that it should be performed on every unclear tumorous lesion of the liver.

[Pseudotumorous hepatic tuberculosis: laparoscopic appearance]

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of a nodular form of local hepatic tuberculosis. There is a growing incidence of the disease related to human immunodeficiency virus. The authors report a case of pseudotumoral hepatic tuberculosis in a patient without AIDS, manifesting as prolonged fever, diagnosed previously as metastatic liver. Imaging studies of the liver and laparoscopic findings suggested metastatic disease. The correct diagnosis was made by histology of biopsies obtained in laparoscopy, which is an easy and cheap method, with less morbidity and mortality than surgical intervention. The case report illustrates the difficulty in reaching the correct diagnosis, most often confused with carcinoma of the liver, primary or metastatic. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the majority of patients respond well to antituberculous chemotherapy.

[A case of tubercular liver and splenic abscesses]

A 34-years male was admitted to our hospital with a hypochondria pain and low grade fever. Abdominal CT revealed an encapsulated 8 x 3 cm low density lesion on the surface of the liver (S5, S8) and multiple low density lesions of the spleen. The patient had already been treated with anti-tuberculous drugs for the past 7 months after being diagnosed as tuberculous pleuritis. Although echo-guided percutaneous needle biopsy was tried for the hepatic lesion, no special finding was obtained. Therefore a diagnostic laparotomy was performed and the hepatic lesion was resected. Abscess formation of the resected lesion was noted. Histopathology of the lesion revealed epithelioid granuloma, but microscopy, culture and PCR for tuberculosis revealed negative results. Abdominal CT, 3 weeks after surgery, revealed enlargement of the splenic lesion. Splenectomy was carried out to avoid splenic rupture. Multiple abscess of the resected spleen was noted. Pathological finding, Ziehl-Neelsen stain and PCR for tuberculosis confirmed the diagnosis of tubercular splenic and liver abscess. Although tubercular liver and splenic abscess are very rare recently, it should be included in the differential diagnosis of unknown hepatic and splenic lesions.

Abdominal macronodular tuberculomas: MR findings

PURPOSE

Our goal was to determine the appearance of abdominal macronodular tuberculomas on MRI.

METHOD

MR findings of two patients with abdominal macronodular tuberculoma, one of the liver and the other in the kidney, were reviewed.

RESULTS

The two tuberculomas, histologically confirmed to have no calcification, hemorrhaging, or fibrosis, commonly showed low signal intensity on both T1- and T2-weighted images.

CONCLUSION

We report two cases of a macronodular tuberculoma in the liver and kidney, which is visualized as a region of hypointensity on T2-weighted MR images. This finding appears to be important in reaching a definitive diagnosis of an abdominal tuberculoma.

The human lysozyme promoter directs reporter gene expression to activated myelomonocytic cells in transgenic mice

The 5' region of the human lysozyme gene from -3500 to +25 was fused to a chloramphenicol acetyltransferase (CAT) reporter gene and three transgenic founder mice were obtained. All three transgenic lines showed the same pattern of CAT enzyme expression in adult mouse tissues that was consistent with the targeting of elicited, activated macrophages in tissues and developing and elicited granulocytes. In normal mice high CAT enzyme activity was found in the spleen, lung, and thymus, tissues rich in phagocytically active cells, but not in many other tissues, such as the gut and muscle, which contain resident macrophages. Cultured resident peritoneal macrophages and cells elicited 18 hr (granulocytes) and 4 days (macrophages) after injection of sterile thioglycollate broth expressed CAT activity. Bacillus Calmette-Guérin infection of transgenic mice resulted in CAT enzyme expression in the liver, which contained macrophage-rich granulomas, whereas the liver of uninfected mice did not have any detectable CAT enzyme activity. Although the Paneth cells of the small intestine in both human and mouse produce lysozyme, the CAT gene, under the control of the human lysozyme promoter, was not expressed in the mouse small intestine. These results indicate that the human lysozyme promoter region may be used to direct expression of genes to activated mouse myeloid cells.

Microabscesses of the liver and spleen in AIDS: detection with 5-MHz sonography

PURPOSE

To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS).

MATERIALS AND METHODS

Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.

RESULTS

The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.

CONCLUSION

In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.

Granulomatous hepatitis: a retrospective study

51 cases of granulomatous hepatitis were seen among 1234 liver biopsies over a 10 year period. Tuberculosis was the commonest cause seen in 55 percent of cases. Other causes included leprosy, sarcoidosis, histoplasmosis, brucellosis, amoebic liver abscess, lymphoma and malignant granuloma. 12 percent of cases remained undiagnosed. Clinically these patients presented with pyrexia and hepatosplenomegaly. Jaundice was uncommon. Many showed elevated alkaline phosphatase levels, anaemia and raised ESR Granulomatous hepatitis of unknown aetiology with FUO was seen in 6 percent cases only.

[The pseudo-tumoral form of hepatic tuberculosis. Five case reports]

The authors report 5 cases of pseudotumoral tuberculosis of the liver. They essentially involved young men from disadvantaged socio-economic backgrounds. Clinically, poor general condition with massive weight loss was constant, while pyrexia and hepatomegaly were sometimes absent. Hepatobiliary ultrasonography revealed hypoechogenic or even anechogenic lesions between 1.5 and 3.5 cm in diameter. Diagnostic confirmation was histological after needle biopsy. The outcome after antibiotic treatment with or without drainage, was recovery, with ultrasonographic normalization of the liver, in all patients, with a mean follow-up of 22 months.